Knowledge Translation and Emergency Medicine. Eddy Lang Jeremy Grimshaw Michael Brown

Transcription

1 Knowledge Translation and Emergency Medicine Eddy Lang Jeremy Grimshaw Michael Brown

2 Knowledge Translation The exchange, synthesis and application of research evidence within a complex system of relationships among researchers and knowledge users.

3 Available evidence Evidence that gets incorporated into practice

4 Glasziou P, Haynes B. ACP J Club Mar-Apr;142(2):A8-10.

5 Dr. Eddy Lang Assistant Professor McGill University EBM undergraduate director Workshop director EBM Series Annals

6 Dr. Jeremy Grimshaw Director of the Clinical Epidemiology Program of the Ottawa Health Research Institute Canada Research Chair in Health Knowledge Transfer and Uptake Co-coordinating editor of the Cochrane Effective Practice and Organization of Care review group EBM Series Annals KT expert in EM research on uptake of decision rules and croup guidelines

7 Dr. Michael Brown Associate Professor of Emergency Medicine and Epidemiology Michigan State University Chair SAEM EBM IG EBM Series Annals KT research VTE

8 Scenario Phase I 43 year old female presents to the with dyspnea and cough that she attributes to asthma Picked up her daughter s URI Can t sleep (presents at 2:00am) Asthma has been quiescent for months no ED visits for over a year Multiple admissions in her 30 s

9 Scenario Phase I Salbutamol at home only, seems to have emptied canister No fever, chest pain, chills ROS and other PMHx unremarkable Anxious and dyspneic on exam RR = 30, incessant coughing, Sat 98% Diminished air entry bilaterally Prolonged expiratory phase and wheezing ++

10 ED Care FEV 1.0 = 50% predicted / Normal CXR Aerosolized salbutamol 2.5mg Q1h x 3 then Q2h Prednisone 50mg PO Gradual improvement over 6-hour stay in the ED Discharge on 5-day course of prednisone and renewed Rx for salbutamol

11 Questions to consider 1. Was the patient s management reasonable? 2. Could this case management have occurred in a North American ED? 3. What critiques would you provide of the management provided for this patient?

12 Scenario Phase II Patient returns 3 days later in severe respiratory distress While generally mild allergic symptoms to cats now very SOB after accidental exposure Had been doing reasonably well on exit Rx No chest pain / no fever

13 Scenario Phase II Appears pale, HR = 130, BP 160/95, RR = 40, Sat 85% (R/A) Patient appears pale, barely able to speak 3 words in succession Marked accessory muscle use Markedly decreased air entry, minimal wheezing

14 ED Care Q15 minute aerosols x 2 (salbutamol 5.0mg) then q30 min 120 mg methylprednisolone IV Heliox and non-invasive positive pressure ventilation doesn t seem to help Minimal improvement over 4-hour stay in the ED Transfer to ICU

15 Questions to consider 1. Was the patient s management reasonable? 2. Could this case management have occurred in a North American ED? 3. What critiques would you provide of the management provided for this patient?

16 ED Care (Phase I) FEV 1.0 = 50% predicted / Normal CXR Aerosolized salbutamol 2.5mg Q1h x 3 then Q2h Prednisone 50mg PO Gradual improvement over 6-hour stay in the ED Discharge on 5-day course of prednisone and renewed Rx for salbutamol

17 Holding chambers versus nebulisers for beta-agonist treatment of acute asthma Cates CCJ, Bara A, Crilly JA, Rowe BH. Cochrane Library March 2003

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19 ED Care (Phase I) FEV 1.0 = 50% predicted / Normal CXR Aerosolized salbutamol 2.5mg Q1h x 3 then Q2h Prednisone 50mg PO? inhaled corticosteroids in the ED Gradual improvement over 6-hour stay in the ED Discharge on 5-day course of prednisone and renewed Rx for salbutamol

20 NNT = 6 Early use of inhaled corticosteroids in the emergency department treatment of acute asthma Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. Cochrane library may 2003

21 ED Care (Phase I) FEV 1.0 = 50% predicted / Normal CXR Aerosolized salbutamol 2.5mg Q1h x 3 then Q2h Prednisone 50mg PO? inhaled corticosteroids Gradual improvement over 6-hour stay in the ED Discharge on 5-day course of prednisone and renewed Rx for salbutamol? what about inhaled corticosteroids

22 NNT = 30 Inhaled steroids for acute asthma following emergency department discharge Edmonds ML, Camargo CA Jr, Brenner BE, Rowe BH. Cochrane Library May 2003

23 ED Care (Phase II) Q15 minute aerosols x 2 (salbutamol 5.0mg) then q30 min 120 mg methylprednisolone IV Heliox and non-invasive positive pressure ventilation doesn t seem to help Minimal improvement over 4-hour stay in the ED Transfer to ICU

24 NNT = 13 Continuous versus intermittent beta-agonists for acute asthma Camargo CA Jr, Spooner CH, Rowe BH. The Cochrane Library July 2003

25 ED Care (Phase II) Q15 minute aerosols x 2 (salbutamol 5.0mg) then q30 min 120 mg methylprednisolone IV Heliox and non-invasive positive pressure ventilation doesn t seem to help Minimal improvement over 4-hour stay in the ED Transfer to ICU

26 Heliox for nonintubated acute asthma patients Rodrigo G, Pollack C, Rodrigo C, Rowe BH. The Cochrane Library January 2003

27 ED Care (Phase II) Q15 minute aerosols x 2 (salbutamol 5.0mg) then q30 min 120 mg methylprednisolone IV Heliox and non-invasive positive pressure ventilation doesn t seem to help Minimal improvement over 4-hour stay in the ED? What about magnesium Transfer to ICU

28 NNT = 7 Magnesium sulfate for treating exacerbations of acute asthma in the emergency department Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. The Cochrane Library October 1999

29 Conclusions Even common medical conditions may not always treated in an evidence-based manner there s work to do! Shifting the balance from evidence availability to application can be achieved in part through awareness of pre-appraised resources

30 Future directions Clinician-friendly evidence summaries for Emergency Medicine Cochrane systematic review summaries in Annals ACPJC relevant to EM No specific resource evidence summaries for EM Evidence synopses may not equate to KT